!

!
1.06!
August,!22,!2016!
HISTORY!TAKING,!DIAGNOSIS!&!PRE7NATAL!CARE!
Dr.!Alicia!D.!Bautista!
Department"of"Obstetrics"and"Gynecology"

TOPIC!OUTLINE! m.""""""Alcohol"
I. Terminologies" m. Caffeine"
a. Gravida"(G)" n. Illicit"Drugs"
b. Parity"(P)" o. Medications"
c. Obstetrical"(OB)"Index" XI. Other"Common"Concerns"During"Pregnancy"
II. Naegele’s"Rule" XII. Drugs"During"Pregnancy"
III. History"Taking" a. Category"A"
a. General"Data" b. Category"B"
b. Chief"Complaint" c. Category"C"
c. Past"Medical"History" d. Category"D"
d. Family"History" e. Category"X"
e. Personal"and"Social"History"
f. Ob/Gyn"History"
"
"
g. Review"of"Systems"
h. Condition"on"Admission"
TERMINOLOGIES!
i. Physical"Examination" Gravida!(G)!
IV. Leopold’s"Maneuver" • A"woman"who"is"or"has"been"pregnant"irrespective!of!
a. 1st""Leopold"Maneuver"(Fundal"Grip)" pregnancy!outcome!
b. 2nd"Leopold"Maneuver"(Umbilical"Grip)" • Twins,'triplet'or'multifetal'pregnancy"is'counted'as'1"
c. 3rd"Leopold"Maneuver"(Pawlic/Pawlik’s"Grip)" • Ectopic!pregnancy"and"H.!mole"are"considered"pregnancy"
d. 4th"Leopold"Maneuver"(Pelvic"Grip)" "
V. Diagnosis"of"Pregnancy" • Ex:""" Currently"pregnant,"1"abortus"→"Gravida!2!(G2)"
a. Presumptive"Evidence" " Currently"pregnant,"1"ectopic"pregnancy,"girl"born"38"weeks""
b. Probable"Evidence" " (now"3"years"old)"→"Gravida!3!(G3)"
c. Positive"Evidence" "
VI. Differential"Diagnosis" Parity!(P)!
a. Distinction"between"1st"and"Subsequent"Pregnancy" • Number"of"pregnancies"reaching"20!weeks"and"not!the!
b. Radiographic"Signs"of"Fetal"Death" number!of!fetuses!delivered!
VII. Prenatal"Care" • Parity"is"1"for"singleton'or'multifetal'delivery'or'live'or'
a. Preconceptional"Care" stillborn"delivery"
b. Initial"Prenatal"Care" "
- Prenatal"Instructions" • Ex:"" Currently"pregnant"with"triplets"(already"25"weeks,"yet""
c. Frequency"of"Visits"
to"be"delivered),"1"stillborn"at"22"weeks"→"Gravida!2!Parity!1!
VIII. Subsequent"Prenatal"Care"
(G2P1)"
a. Gestational"Age"
b. Prenatal"Surveillance" 1st"time"mom,"abortus"at"14"weeks"→"Gravida!1!Parity!0!
c. Subsequent"Lab"Tests" (G1P0)!
IX. Nutrition" !
a. Recommended"Dietary"Allowances" Transers’!Note:!In!Gravida,!the'current'pregnancy'is'ALWAYS!counted.'
b. Calorie" But'in'Parity'it'is!NOT.'!'Wag'kalimutan,'guys!!
c. Proteins"
d. Carbohydrates" !
Obstetrical!(OB)!Index!(T7P7A7L)!
e. Fats"
f. Dietary"Fiber" • 4!digits"connected"by!(7)"
g. Minerals" • 1st:"refers"to"the"no."of"Term!infants!(>37!weeks)"
h. Vitamins" • 2nd:"refers"to"the"no."of"Preterm!infants!(<37!weeks)"
X. General"Hygiene:"Common"Concerns" • 3rd:"refers"to"the"no."of"Abortion!(<20!weeks)"(includes"
a. Exercise" ectopic"pregnancy,"bligthed"ovum)"
b. Employment" • "4th:"refers"to"the"no."of"Living!children!(currently!alive)"
c. Travel" "
d. Bathing" • Ex:" Currently"pregnant"at"14"weeks,"delivered"twins"born""
e. Clothing" 38"weeks,"1"abortus,"1"baby"boy"delivered"at"35""
f. Bowel"Habits" Weeks"→"Gravida!4!Parity!2,!Term!2!Pre7Term!1!!
g. Coitus" Abortion!1!and!Living!3!→!G4P2!(2717173)!
h. Douches"
!
i. Care"of"Breast"and"Abdomen"
j. Care"of"Teeth/Dentition" Transers’!Note:!Laging'lagyan'ng!(5)!in'between'OB'Index!!
k. Immunizations" In'OB'Index,'ALWAYS'mong'i5count'lahat'ng'delivered!na!fetuses.'
l. Smoking" Example:'If'twins,'one'gravida'sya'pero'sa'OB!Index!two'na'sila.'Gets?'!!

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1"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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 History!Taking,!Diagnosis,!and!Prenatal!Care!
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NAEGELE’S!RULE! Other!Terminologies!
• Used"to"estimate"expected"date"of"delivery"(EDD)"or" • PRIMIGRAVIDA!!
expected"date"of"confinement"(EDC)" o A"woman"who"is"in"or"has"experienced"her!first!pregnancy"
• Add"7!days!to!1st!day!of!LMP"and"count!back!3!months" • MULTIGRAVIDA!
" o A"woman"who"has"been"pregnant"more!than!once"
• NULLIGRAVIDA!
Transers’!Note:"Laging'tandaan,'Naegele’s'Rule:'53M!(months)!+7D!
o A"woman"who"has"never!been"or"is"not"pregnant"
(days).!!
• PRIMIPARA!
If'0'ang'lalabas'kapag'nagminus'ka'sa'months,'magplus'ka'muna'ng'12'sa' o A"woman"who"has"delivered!for!the!first"time"a"fetus"or"
months'before'subtracting'3.'' fetuses,"alive"or"dead"with"an"estimated"length"of"gestation"of"
Example:'''LMP'='February'10,'2016'(02/10/2016)' 20!or!more!weeks"
' Add'muna'ng'12'sa'month'→'12'+'2'='14' • MULTIPARA!
' Then'subtract'3'→'14'–'3'='11'(November)' o A"woman"who"has"delivered"more!than!once"a"fetus"or"
' Add'7'sa'days'→'10'+'7'='17' fetuses,"who"is/are"alive"or"dead"with"an"estimated"length"of"
' EDC/EDD!=!11/17/2016! gestation!of!>20!weeks"
• NULLIPARA!
Same'with'kung'magplus'ka'ng'7'tapos'sobra'sa'30'or'31'ang'sum.'I\adjust'
o Never"completed"a"pregnancy"beyond!20!weeks"gestation."A"
mo'na'lang'sa'depende'sa'month.''
woman"can"be'multigravid'but'nullipara'at'the'same'time.'
Example:'''LMP'='December'27,'2015'(12/27/2015)'
• PARTURIENT!
' Subtract'3'sa'month'→'12'–'3'='9'(September)' o A"woman"in"labor"
' Add'7'sa'days'→'27'+'7'='34' • PUERPERA!
' Adjust'9/34'(Sept'34,'since'Sept'ay'hanggang'30'lang,'' o A"woman"who"has"just!given!birth"
''''''''''''''''''''ADJUST!)'→'10/04'(October'04)' !
' EDC/EDD!=!10/04/!2016! HISTORY!TAKING!AND!PHYSICAL!EXAMINATION!
WAG!KALIMUTAN!ANG!PAG5ADJUST!NG!YEAR.!OK?!! ! General!Data!
" • Name,"age,"sex,"marital"status,"religion"(some"don’t"allow"
Examples! blood"transfusion"e.g."Jehovah’s"witness)"
E.A.,"33"years"old,"consulted"the"OPD"today"(July"15,"2013)"because"of" • OB"index"
bloody"mucoid"discharge"for"1"hour." • Address"
" • Name"of"hospital"
LMP:"December"7,"2012"PMP:"November"9,"2012" • Number"of"admissions"
FHT:"150"min"PE:"Normal" • Date"of"admission"
" "
She"had"twin"boys,"7"years"old"at"36"weeks"by"CS,"4"years"old"girl"born"at" Chief!Complaint!
39"weeks,"blighted"ovum"and"D"&"C"was"done"4"years"ago"and"10"months" • CC"of"the"patient"(e.g.'watery'vaginal'discharge,'hypogastric'pain,'
old"girl"born"at"37"weeks."Determine"the"Gravida,"Parity,"OB"Index,"EDD" lumbosacral'pain)"
and"AOG." "
" Past!Medical!History!
ANSWERS:! • History"of"mumps,"measles"and"chicken"pox"
Gravida!–!5! • Cesarean"delivery"is"not"included"
• Medications"
1st"pregnancy"g"7"year"old"twin"boys"
"
2nd"pregnancy"g"4"year"old"girl"
Family!History!
3rd"pregnancy"g"blighted"ovum"
• HPN"and"DM"
4th"pregnancy"g"10"months"old"girl"
"
5th"pregnancy"g"current" Personal!and!Social!History!
Parity!–!3! • Educational"attainment"
1st"g"twin"boys" • Smoking"
2nd"g"4"year"old"girl" • Alcohol"consumption"
3rd"g"10"months"old"girl" • Occupation"(i.e."sexual"workers)"
• Spouse/partner"(i.e."sexual"history"of"partner"which"may"help"in"the"
Term!–!2! diagnosis"of"sexually"transmitted"infections"and"diseases)"
1st"g"4"years"old"born"at"39"weeks" "
2nd"g"10"months"old"girl"born"at"37"weeks" Ob/Gyn!History!
Preterm!–!2!–"twins"born"at"36"weeks! • Menstrual"history"
Abortion!–!1"–"blighted"ovum" o Age"of"menarche"
! Duration,"character"of"flow,"number"of"napkins"consumed"
Living!–!4! (subjective;'type'of'napkin'must'be'noted),"accompanying"
2"boys"g"both"aged"7"years" signs"and"symptoms"(e.g."dysmenorrhea)"
2"girls"g"4"years"old"and"10"months"old" o Subsequent"Menses"
! Regularity"of"cycle,"duration,"characteristic"of"flow,"
Gravida,!Parity,!and!OB!INDEX:!G5P3!(2525154)!
number"of"napkins"used"and"accompanying"signs"and"
EDD:!!September!14,!2013! symptoms"
AOG:!220!days!or!31!weeks!and!3!days! • Age"of"1st"coitus"
! • Number"of"sexual"partners"

2"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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 History!Taking,!Diagnosis,!and!Prenatal!Care!
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• History"of"postgcoital"bleeding,"pelvic"infections,"dyspareunia"
• Method"of"contraception"(length"of"time"used,"complications)"–""may'
determine'risk'for'infertility"
o ex:"A"couple"who"does"not"use"any"method"of"contraception"for"7"
years"and"the"wife"is"still"nulligravida"
• LMP"(last"normal"menstrual"period)"
• PMP"(previous"menstrual"period)"
• GP(TgPgAgL)"
• History"of"pregnancies"and"deliveries"
o G1"–""date"of"delivery,"ND"or"CS"due"to"_______,"place"of"delivery,"
delivered"by"_______,"boy"or"girl,"weight,"fetogmaternal"Cx,"
present"status"
• History"of"present"pregnancy"
o LMP"
o PMP"
o EDC"
o AOG"
o 1st!trimester"–"what"were"the"mother’s"experiences"
o 2nd!trimester"–""what"is"the"BP"during"1st"trimester," "
regular/irregular"prenatal"checkup,"what"are"the"prenatal" Transers’!Note:'FUNDIC!HEIGHT'is'measured'from'upper!border!of!
diagnoses,"regular/irregular"vitamins" symphysis!pubis!(@12!weeks)'to'upper'border'of''fundus'
o 3rd!trimester!–""what"is"the"present"condition,"history"of" 24534!weeks!–'fundic'height'is'approximately'equal'to'AOG.!
present"condition,"PQRST" @!20!weeks,!FH!is!at!the!level!of!umbilicus.!
o Ask"the"patient"to"bring"the"results"of"the"laboratory"tests"done" !
during"the"pregnancy"
LEOPOLD’S!MANEUVER!
"
• Palpation"
Transers’!Note:"LMP'ay'‘yung'unang!araw'ng'huling'mestrual'period.'
• Mother"is"in"supine"position,"abdomen"is"bared"
(Doc'Bautista,'2016)!
• During"1st"3"maneuvers"–"examiner"stands"at"the"side"of"the"bed"
" facing"the"patient"
Review!of!Systems! • During"the"last"maneuver"–"examiner"faces"the"feet"of"the"patient"
• Constitutional" • Maneuvers"maybe"difficult"to"perform"if"mother"is"obese"or"if"
• Hematologic" placenta"is"anteriorly"implanted"
• CNS" • Provides"info"about"presentation"and"position"of"fetus,"and"
• Respiratory" extent"to"which"presenting"part"has"descended"into"the"pelvis."!
• CVS" "
• GIT" 1st!Leopold!Maneuver!(Fundal!Grip)!
• GUT" • Examiner"gently"palpates"fundus"with"tips"of"fingers"of"both"hands"
• NMS" to"define"which"fetal"pole"is"present"in"the"fundus"
" • Differentiate"whether"the"fetus"is"breech"or"cephalic"
Condition!on!Admission! o Breech"–"large"nodular"body;"buttocks"""CEPHALIC!
• BP" PRESENTATION"
• PR" o Cephalic"–"feels"hard"and"round;"more"freely"movable;"
• HR" ballotable"""BREECH!PRESENTATION"
• Weight" o Nothing"is"palpable"""TRANSVERSE!PRESENTATION"
• Body"temperature" "
" 2nd!!Leopold!Maneuver!(Umbilical!Grip)!
Physical!Examination!
• Palms"placed"on"either"side"of"the"abdomen,"and"gently"but"deep"
• Abdomen:"FHT,"LM14,"FH" pressure"is"exerted"
o empty"the"bladder"first"before"examining"the" o Fetal!back"–"hard"resistant"structure"
o abdomen." o Fetal!extremities"–"numerous,"small,"irregular,"mobile"
o use"a"tape"measure"when"measuring"fundic"height." parts"
• Extremities" "
• Speculum"examination" 3rd!!Leopold!Maneuver!(Pawlic’s/Pawlik’s!Grip)!
• Internal"examination"
• Using"thumb"and"fingers"of"one"hand,"lower"portion"of"abdomen"is"
• Rectovaginal"examination"
grasped"above"the"symphysis"pubis"
"
• Differentiation"between"head"and"breech"is"made"in"the"first"
maneuver"
• If"the"presenting"part"is"not"engaged"→'movable"part"
• Define"attitude"of"head"if"presenting"part"is"not"engaged:"
o If"cephalic"prominence"is"on"the"same'side"as"the"small!
parts"→"head"is"flexed"(VERTEX!POSITION)"
o If"cephalic"prominence"is"on"the"same'side"as"the"back"→"
head"is"extended"(FACE!PRESENTATION)"
• If"presenting"part"is"engaged,"details"are"defined"during"LM4"
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3"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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 History!Taking,!Diagnosis,!and!Prenatal!Care!
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4th!!Leopold!Maneuver!(Pelvic!Grip)! • Chadwick’s!sign!
• Examiner"faces"the"mother’s"feet!and,"with"the"tips"of"the"first"three" o (When"was"the"LNMP?"Bleeding?)"discoloration"of"vaginal"
finger"of"each"hand,"exerts"deep"pressure"in"the"direction"of"the"axis" mucosa"
of"the"pelvic"inlet" • ↑!Pigmentation!and!development!of!abdominal!striae!
• When"the"head"has"descended"into"the"pelvis,"the"anterior"shoulder" • Pseudocyesis!
may"be"differentiated"readily"by"LM3" o Does"the"woman"believe"she"is"pregnant?"
• If'necessary,'you'can'do'internal'exam,'speculum'exam" • Pwede'pang'i\deny'ng'father..'“Feel'mo'lang'‘yan!”"
" "
Probable!Evidence!
• Basically"the"signs"or"what"the"examiner"can"see/feel""
• Enlargement"of"abdomen"
• By!12!weeks,"uterus"is"palpated"above"the"symphysis"pubis"
• Less"pronounced"in"primipara,"because"in"multipara,"the"tone"of"
abdominal"muscle"was"lost"in"previous"pregnancies"
• Changes"in"size,"shape"and"consistency"
• Hegar’s!sign"g"softening"of"isthmus"
• Goodell’s!sign"g"softening"of"cervix"
• Braxton"Hicks"contraction"
• Pwede'pa'ring'i\deny.'Pagdating'ng'pregnancy'test,'pwede'sabihin'ng'
father'na'“baka'factory'defect'lang'‘yan!'Wala'‘yan!”"
"
Transers’!Note:"Ang'Chadwick’s!Sign'ay'presumptive'evidence'while'ang'
Hegar’s'and'Goodell’s'ay'probable'evidence.'!'
!
Positive!Evidence!
• Identification"of"fetal!heart"action"separately"and"distinct"from"that"
of"pregnant"woman"(FHT!1107160!bpm)"
• Stethoscope:"17g19"weeks"
• Doppler"principle"g"10"weeks"
• On"auscultation"of"FHT,"other"sources"can"be"heard:"
! Funic""(umbilical"cord)"soufflé"
- rush"blood"through"umbilical"cord"
- arterial"–""sharp,"whistling"sound"synchorous"with"
fetal"pulse"
! Uterine"Soufflé"
- soft,"blowing"sound"synchronous"with"maternal"
pulse"
- produced"by"passage"of"blood"through"dilated"
! uterine"vessels"
Leopold’s"Maneuver." - heard"distinctly"near"the"lower"uterine"portion"
! ! Sounds"from"movement"of"fetus"
DIAGNOSIS!OF!PREGNANCY! ! Maternal"pulse"
Presumptive!Evidence! ! Gurgling""of"gas"in"the"intestine"of"pregnant"woman"
• Perception"of"active!fetal!movement!by"the"examiner"
• Based"largely"on"subjective"–!symptoms"(what"the"mother"can"feel"–"
• Recognition"of!embryo!or!fetus!by!ultrasound/!sonographic"
except"for"the"Chadwick’s"Sign"which"can"be"seen"by"the"examiner)"
• Hinding\hindi'na'maidedeny.'Hello,'baby'na.'!"
• Nausea!g"w/"or"w/o"vomiting,"disturbance"of"digestive"system"
(morning"sickness"of"pregnancy)" "
• Disturbance!of!urination! Transers’!Note:"A'normal'fetal'heart'rate'(FHR)'usually'ranges'from'120!
o (urinalysis"to"check"for"UTI."Is"it"a"pregnancy"with" to!160!beats!per!minute(bpm)'in'the'in'utero'period.'It'is'measurable'
concomitant"UTI?)"–"during"early"pregnancy"there"is"an" sonographically'from'around'6'weeks'and'the'normal'range'varies'during'
gestation,'increasing'to'around'170!bpm'at'10'weeks'and'decreasing'from'
increase"in"frequency"in"urination"
then'to'around'130!bpm'at'term.'(From'radiopaedia.org/articles/fetal\
o mid7pregnancy:"uterus"lifted"out"of"the"pelvis"–"micturition" heart\rate)'
normal" "
o at!term:"head"of"the"fetus"descends"into"the"pelvis"frequency"
increases" DIFFERENTIAL!DIAGNOSIS!
• Fatigue! • Myomas!
• Perception!of!fetal!movement! o Is"it"an"ovarian"mass"or"GI"mass?"
o bet."16g20"weeks" • Hematometra!
o slight"fluttering"movements"in"abdomen"="“quickening”" o a"medical"condition"involving"collection"or"retention"of"blood"
="perception"of"life" in"the"uterus"
• Adenomysis!
• Cessation!of!menses!
o occurs"when"endometrial"tissue,"which"normally"lines"the"
o When"was"the"LNMP?"Bleeding?"
uterus,"exists"within"and"grows"into"the"muscular"wall"of"the"
o Hartman!sign:"implantation"bleeding,"which"coincides"with"
uterus"
expected"menses"
• Extrauterine!mass!
• Anatomical!changes!in!breast!(tenderness,!↑!size)!

4"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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Distinction!between!1st!and!Subsequent!Pregnancy!
• NULLIPARA!
o abdomen"is"tense"and"firm""
o abdominal"stria"and"breast"changes"absent""
o labia"majora"in"close"apposition""
o vagina"with"narrow"and"well"developed"rugae""
o cervix"does"not"admit"tip"of"examining"finger""
o frenulum"intact""
• MULTIPARA!
o abdominal"wall"is"lax"and"pendulous,"silvery"cicatrises""
o vulva"gates"open""
o breasts"not"so"firm,"with"striae"(sagging)""
o frenulum"has"disappeared""
o hymen"is"multiform"caruncles""
o external"os"admits"tip"of"examining"fingers""
Radiographic!Signs!of!Fetal!Death!
• SPALDING!SIGN!!
o significant"overlap"of"the"skull"bone"due"to"liquefaction"of"the"
brain""
• ROBERT’S!SIGN!
o demonstration"of"gas"in"fetal"spines"
• Exaggerated!curvature!of!the!fetal!spine!!
PRENATAL!CARE!
• Comprehensive"antepartum"care"program"involving"a"coordinated"
approach"to"medical"care"and"psychosocial"support"that"optimally"
begins"before"conception"and"extends"throughout"the"antepartum"
period"
• Program!includes:!
o preconceptional"Care"
o prompt"diagnosis"of"Pregnancy"
o initial"prenatal"evaluation"
o followgup"prenatal"visits"
• Lowers'maternal'mortality'rates,'rates'of'pre\term'births'and'
neonatal'deaths'
• Good'time'to'explain'proper'breastfeeding,'indications'of'caesarean'
pregnancy,'and'expectations'during'pregnancy'including'financial'
ones'
"
Preconceptional!Care
• Integral'preclude'to'prenatal'care'because'health'before'pregnancy'
affects'health'during'pregnancy'
• Assists'woman'by'reducing'risks,'promoting'healthy'lifestyles'and'
improving'readiness'for'pregnancy'
' above)!
Initial!Prenatal!Care!
• Prenatal"care"should"be"initiated"as"soon"there"is"reasonable"
likelihood"of"pregnancy.""
• The!major!goals!are:"
o to"define"the"health"status"of"the"mother"and"fetus"
o to"estimate"the"gestational"age"
o to"initiate"a"plan"for"continuing"obstetrical"care"
• Components!of!prenatal!evaluation!
o History"
o Physical"Examination"
o Laboratory"tests"
! •
A.!HISTORY!
o Detailed"information"concerning"past"obstetrical"history"is"
crucial"because"many"prior"pregnancy"complications"tend"
to"recur"in"subsequent"pregnancies.""
o The"menstrual"hx"is"extremely"impt."Without"a"history"of"
regular,"predictable,"cyclic,"spontaneous"menses"that"
suggest"ovulatory"cycles,"accurate"dating"of"pregnancy"by"
history"and"physical"examination"is"difficult.""
History!Taking,!Diagnosis,!and!Prenatal!Care!
o It"is"also"important"to"ascertain"whether"or"not"steroidal"
contraceptives"were"used"before"the"pregnancy."Because"
ovulation"may"not"have"resumed"2"weeks"after"the"onset"of"
the"last"withdrawal"bleeding"and"instead"may"have"
occurred"at"an"appreciably"later"and"highly"variable"date,"
using"the"time"of"ovulation"for"predicting"the"time"of"
conception"in"this"circumstance"may"be"erroneous.""
• PSYCHOSOCIAL!SCREENING!!
o Psychosocial"risk"factors"as"nonbiomedical"factors"that"
affect"mental"and"physical"wellgbeing"
• CIGARETTE!SMOKING!!
o Numerous"adverse"outcomes"have"been"linked"to"smoking"
during"pregnancy."Potential"teratogenic"effects""
o High"risk"of"placenta"previa,"placental"abruption,"and"
premature"membrane"rupture"compared"with"nonsmokers.""
o More"likely"to"be"born"preterm,"may"die"of"SIDS,"risks"for"
spontaneous"abortion,"fetal"death,"and"fetal"digital"
anomalies"are"also"increased""
o The"most"successful"efforts"for"smoking"cessation"during"
pregnancy"involve"interventions"that"emphasize!how!to!
stop!!"
! Asks"about"smoking"status""
! Advises"those"who"smoke"to"stop""
! Assesses"the"willingness"to"quit"within"the"next"30"
days""
! Assists"interested"patients"by"providing"pregnancyg
specific"selfghelp"materials""
! Arranges"followgup"visits"to"track"progress""
• ALCOHOL!USE!DURING!PREGNANCY!!
o Ethanol"is"a"potent"teratogen"and"can"cause"fetal""""alcohol"
syndrome"characterized"by"growth"restriction,"facial"
abnormalities,"and"central"nervous"sysg"tem"dysfunction""
o Women"who"are"pregnant"or"considering"pregnancy"should"
abstain"from"using"any"alcoholic"beverages.""
• ILLICIT!DRUG!USE!!
o Wellgdocumented"sequelae"include"fetal"distress,"low"
birthweight,"and"drug"withdrawal"soon"after"birth.
• DOMESTIC!VIOLENCE!SCREENING!!
o Violence"against"adolescent"and"adult"females"within"the"
context"of"family"or"intimate"relationships.""
!
B.!PHYSICAL!EXAMINATION!&!LEOPOLD’S!MANEUVER!(discussed!
• Inspect"the"ocular"fundi,"ears,"nose,"heart"&"lungs,"breast,"
abdomen,"extremities,"weight"and"BP""
• At"time"of"examining"of"the"breast,"the"value"of"breastfeeding"
should"be"emphasized""
• In"examination"of"lower"ext,"the"venous"pattern"should"be"
carefully"recorded"at"the"initial"visit"since"varicosities"tend"to"
appear"or"worsen"during"the"pregnancy""
• Determine"the"Lie,"Presentation"&"Position"via"Leopold’s"
maneuver,"Vaginal"Examination,"Pelvic"Examination"or"Rectal"
and"Rectovaginal"Examinations""
• Determine"the"Fundic"height"(discussed"above)""
Vaginal!Examination!!
o Inspection"""palpation""
o Inspection:"vulva"and"describe"local"lesions""
o The"cervix"is"visualized"employing"a"speculum"lubricated"
with"warm"water"or"watergbased"lubricant"gel.""
o Chadwick’s"sign:"Bluishgred"passive"hyperemia"of"the"cervix"
is"characteristic""
o Nabothian!cysts:"Dilated,"occluded"cervical"glands"bulging"
beneath"the"ectocervical"mucosa""

5"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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 History!Taking,!Diagnosis,!and!Prenatal!Care!
! !
!
• Character"of"secretion:"" Cervical!cystology!(Pap! To"screen"for"cervical"
o Normal:!white,!non7foul!smelling,!moderate!amount!! smear)! dysplasia/cancer"
o Chlamydia!trachomatis:"foamy"yellow"liquid""
o Candida"infection:"curdglike"discharge"" Subsequent!Assessments!
o Gardiarella!vaginalis"vaginitis:"grayish"discharge"" Cervical!culture!for! Screen"for"infection"
• Palpation:"consistency,"length,"and"dilatation"of"the"cervix"" Neisseria!gonorrhea!
• Uterine"size"and"any"adnexal"masses"" Hemoglobin!electrophoresis! To"detect"sicklegcell"trait"
• Fetal"presentation"later"in"pregnancy"" (HbSA);"talassemias"
• Bony"architecture"of"the"pelvis"" HIV!titer!by!ELISA;!Western! Offered"to"all"patients"at"risk"
• Any"anomalies"of"the"vagina"and"perineum."" blot!if!HIV!+!by!ELISA! (multiple"sexual"partners,"
! drug"usem"or"sexual"contact"
C.!ROUTINE!ANTEPARTAL!TESTS! with"drug"users);"may"be"
• Kessner!Index!Criteria!! offered"to"all"patients"at"
o Measures'prenatal'care'adequacy'and'not'the'quality'of'care' physician’s"discretion"
nor'the'relative'risk'of'complications'' Glucose!screening! To"screen"for"glucose"
o Incorporates'length'of'gestation,'timing'of'first'prenatal'visit' intolerance"in"highgrisk"
and'number'of'visits'' patients;"usually"at"28"weeks"
' in"low"risk"patients"
! Adequate!Prenatal! Inadequate! MSAFB!at!15!to!18!weeks! Elevated"levels"seen"with"NTD,"
Care! Prenatal!Care! (usually!with!hCG,!estriol)! gastoschisis,"and"
Initial!visit! During"1st"trimester" 3rd"trimester" omphalocoele;"low"levels"
Weeks!17! 2"or"more"visits" None" assoc"with"Down"Syndrome"
Weeks!18721! 3"or"more"visits" None"
Weeks!22725! 4"or"more"visits" o Urine' protein' assessment,' urine' culture,' rubella,' syphilis' and'
1"or"fewer"
Weeks!26729! 5"or"more"visits" heap'B'serology'and'chlamydial'culture'are'done'during'the'
Weeks!30731! 6"or"more"visits" 2"or"fewer" 1st'visit.''
Weeks!32733! 7"or"more"visits" 3"or"fewer" o Fetal' apneuploidy' screening,' neural\tube' defect' screening'
Weeks!34735! 8"or"more"visits" and'cystic'fibrosis''
Weeks! 36! and! 4"or"fewer" "
9"or"more"visits"
more! !
! Prenatal!Instructions!
Typical!Components!of!Routine!Prenatal!Care! • Inform" the" patient" of" any" problem" and" discuss" the" " " plan" of"
' 1st' 15\20'' 24\28' 29\41' management."
visit' weeks' weeks' weeks' • Antepartum"educational"program"
History! "' "" "" "" • Explain"future"visits"
Physical!Examination! "' "" "" "" • Give" instructions" about" diet," relaxation," sleep," bowel" habits,"
Pelvic/Cervical!Examination! "' ' ' ' exercise," bathing," recreational" activities," sexual" intercourse,"
Laboratory!Test! ' ' ' ' smoking,"drug"and"alcohol"use."
Hct!or!Hgb! "' ' "' ' • Diet:"NO!to!high!fat!and!salt,!and!NO!too!much!food!intake"""to"
Blood!type!and!Rh!factor! "" ' ' ' avoid"being"overweight,"as"well"as"hypertension""
Antibody!screen! "" ' ' ' • Relaxation"&"sleep""
Pap!smear!screening! "' ' ' ' • Sexual"Intercourse""
Glucose!tolerance!test! ' ' "' ' o Safe!up!to!term"if"no"history"of:""
o Vaginal"discharge""
o Premature"labor""
Test! Discussion! o Threatened"abortion"or"pregeclampsia""
o If!both!parties!are!comfortable!!
CBC! To"determine"hematologic"
• Bowel"habits""
status;"to"rule"out"anemia"
o Discouraged"giving"of"laxatives""
o Increase"fiber""
Urinalysis,!Urine!Culture,! To"evaluate"for"UTI"and"Renal" • Clothing""
Sensitivity! Function" o Avoid"clothes/jeans"tight"fitting""
Blood!group,!Rh!! To"detect"Blood"type,"Rh" • Drug"&"alcohol"ingestion""
status,"and"risk"of" • Recreation""
immunization" • Smoking""
Serologic!Test!for!Syphylis! To"detect"previous/current" • Exercise""
(RPR,!VDRL)! infection;"if"(+)"specific" • Discuss"the"economic"aspect"of"pregnancy""
treponemal"test"is"required" • Emphasize"danger"signals"
HepaB!surface!antigen! To"detect"carrier"status"or" !
active"dse" DANGER!SIGNALS!(Consult!immediately!)!*signs'of'pre\eclampsia'!
o Vaginal"bleeding"
Rubella!Titer! If"pt"is"seronegative,"special"
o Persistent"vomiting"
prec"are"needed"to"avoid"
o Abdominal"pain"
infection"
o Swelling"of"the"face"or"fingers*""
Vaccination"is"required" o Severe"or"continuous"headache*""
postpartum" o assess"for"history"of"migraine""

6"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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! !
!
o Dizziness"or"blurring"of"vision*""
o Chills"or"fever"
o Dysuria"
! UTI"is"common"during"the"first"trimester"
! escape"of"fluid"from"the"vagina"(urine"is"controllable,"
might"be"mistaken"with"waterbag"fluid)"
! marked"change"in"frequency"or"intensity"of"fetal"
movements"
! quickening"can"be"felt"at"16th"week/4th"month"
! ↑"activeness"of"the"baby,"↑normal"
! normal"fetal"movt"counting"≥"10"active"movts/day,"<10"is"
dangerous"
" globin"if"indicated""
Transers’!Note:"Diabetes'mellitus'in'pregnancy.'All'Filipino'gravidas'are'
considered'“high'risk”'by'race'or'ethnic'group'(Pacific'Islander)'and'should'
be'screened'for'type'II'DM'in'1st'prenatal'visit.'If'there'are'no'other'risk'
factors'and'the'initial'test'is'normal,'test'again'after'24\28'wks'using'a'2'hr'
75'g'OGTT.'(Source:'Doc'Bautista’s'slide;'POGS'CPG'on'DM'in'pregnancy'
2011)'
Frequency!of!Visits!
• Intervals"of"4!weeks"until"28!weeks"
• Intervals"of"2"weeks"from"29!to!36!weeks"
• Weekly!thereafter"(37!weeks!until!delivery)"
• For!high!risk!group"–"more"frequent"visits"depending"on"the"risk"
factors"present"
History!Taking,!Diagnosis,!and!Prenatal!Care!
! Can"be"bizarre"e.g."craving"for"soil""
o HYPEREMESIS!GRAVIDARUM!(HG)!
! A"complication"of"pregnancy"that"is"characterized"by"
severe"nausea"and"vomiting"such"that"weight"loss"and"
dehydration"occur"
Subsequent!Lab!Tests!!
• 16g18"weeks:"maternal"serum"alpha"fetoprotein"(AFP)"to"detect"
open"neural"tube"defects""
• 24g28"weeks:"screen"for"gestational!diabetes"(glucose"tolerance"
test"–"75"g"oral"glucose)""
• 28"weeks:"Dgnegative"women"for"antibodies;"give"antigD"immune"
• Hematocrit"and"hemoglobin"determination,"and"syphilis"serology"if"
its"prevalent"in"the"population"should"be"repeated"28g32"weeks""
• Screening"for"STD""
• Serological"test"for"HIV""
• Group!B!Streptococcus!infection!–"vagina"and"rectal"""""""culture"by"
35th"to"37th"week"
"
"
NUTRITION!
• WEIGHT!GAIN:!12.5!kg"(27.5"lbs)"" ""
• Recommended!weight!gain!based!on!BMI!(2017B'trans)!

SUBSEQUENT!PRENATAL!CARE!
• Maternal"evaluation"(BP,"weight,"symptoms,"FH,"LM,"IE)"
• Fetal"evaluation"
• FHT,"size"of"fetus,"presenting"part"
!
Gestational!Age!!
• Obtained"every"prenatal"checkgup""

Prenatal!Surveillance!
• FETAL!!
o Fetal"heart"rate"(FHR)""
o Size"of"fetus"(es),"actual"&"rate"of"change"(fundic"height)""
o Amount" of" amniotic" fluid" (by" ultrasound)" =" amniotic" fluid"
index"(N:">"10"cm)"obtained"from"ultrasound"" !
o If"≤"5"cm,"SHOULD"be"delivered"" *The'American'academy'of'pediatrics'and'the'American'College'of'
o Presenting"part"&station"(late"in"pregnancy:37th–38th"week)"" Obstetricians'and'Gynecologists'have'endorsed'the'guidelines'above.'
o Leopold" maneuver:" The" findings" provide" info" about" the" *In'this'guideline,'concern'was'focused'on'low\birthweight'infant.'''
position"of"the"fetus"&"the"extent"to"which"the"presenting"part" '
has"descended"into"the"pelvis"" (2018B'trans)'
o Fetal" activity" –" e.g" movement" below" à" breach" pregnancy" –" Weight!in!kg! BMI!
patient"feel"like"urinating"" 12.5g18" Underweight"
11.5g16" Normal"weight"
• MATERNAL!! 7g11.5" Overweight"
o BP"="current"&"extent"of"change"" "
o Weight"="current"&"amt"of"change"" • Obesity'is'associated'with'significantly'increased'risks'for'
o Symptoms!include:!! gestational'hypertension,'preeclampsia,'gestational'diabetes,'
! headache"" macrosomia'and'caesarean'delivery."
! fever"" • 9"kg:"maternal!physiologic!volume!increase!="placenta,"
! altered"vision"" amniotic"fluid,"uterine"hypertrophy,"increased"maternal"blood"
! abdominal"pain"" volume,"breast"enlargement,"&"maternal"&"extravascular"fluid""
! nausea"&"vomiting"" • 3.5"kg:"maternal!storage!fat!"
! bleeding"" • 8g20"weeks"="0.7!lb/wk!"
! vaginal"fluid"leakage"" • 20"weeks"–"delivery"="1!lb/wk!"
! dysuria"" • The"range"for"women"carrying"twins"is"35g45"lbs"(16g20"kg)."
! fundic"height"="usually"at"level"of"umbilicus"at"5th"month" "
! Internal"Exam"–"may'or'may'not'be'done'" "
o PICA!! "
! The"practice"of"craving"substances"with"little"or"no" "
nutritional"value" "

7"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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! !
!
WEIGHT!LOSS! Calorie"
"

"
! "
• Post!Partrum!weight!loss:! • Additional"80,000"kcal"which"are"accumulated"primarily"in"the"
o Immediately'after'delivery"="5.5"kg"or"12"lbs" last"20"wks""
o 2'wks'postpartrum"="4"kg"or"8.8"lbs" • Caloric"increase"of"1007300!kcal/day"
o Between'2'wks'to'6'mos'postpartrum"="2.5"or"5.5"lbs"
• “It'is'recommended'that'the'1989'RDA'recommendation'of'
• Ave!wt!loss"="12.2"±"4.6"kg"
additional'300'kcal/day'during'the'second'and'third'trimester'be'
• Retained!wt"="1.4"to"4.7"kg"(3"±"10.5"lbs)" retained”'[Recommended'Energy'and'Nutrient'Intake,'2002,'
• The'more'weight'gained'during'pregnancy,'the'more'is'lost' FNRI\DOST]"
postpartum." • Calories"are"necessary"for"energy,"and"if"calories"are"inadequate,"
• There'is'no'relationship'between'pre\pregnancy'BMI'or'prenatal' protein"is"metabolized"rather"than"being"spared"for"its"vital"role"
weight'gain'and'weight'retention." in"fetal!growth!and!development!and"for!maintenance!of!
• Accruing'weight'with'age\rather'than'parity\is'considered'the' maternal!tissue"
main'factor'affecting'weight'gain'over'time." "
• Prenatal"Care"is"the"best"time"to"educate"the"woman"about"the" Proteins!
benefits"of"breastfeeding"and"family"planning."" • Additional"protein"intake"of:"
" o 2.9!g/day!during"1st"trimester""
" o 15!g/day!during"3rd"trimester""
Recommended!Dietary!Allowances! o !or"an"average"of"9!g/day!throughout"pregnancy""
" • Function:"
o growth"&"repair"of"the"fetus,"placenta,"uterus"&"breasts"
o increased"maternal"blood"volume"
o maintenance"of"hemoglobin"producing"factors"in"the"liver"&"
plasma"proteins""
o proper"absorption"of"calcium"from"the"GIT"
• During"the"2nd"half"of"pregnancy,"about"1,000!g!of"proteins"are"
deposited,"amounting"to"576!g/day!"
• Food"sources"g"preferably"animal"sources"and"milk"and"dairy"
products"
• The'basic'needs'of'the'non\pregnant'woman'are'added'to'the'
demands'of'growth'and'remodeling'of'the'fetus,'placenta,'uterus'
and'breasts'as'well'as'increased'maternal'blood'volume."
• The'concentrations'of'most'amino'acids'in'maternal'plasma'fall'
markedly,'including'ornithine,'glycine,'taurine'and'proline.'
Exceptions'are'glutamic'acid'and'alanine'which'rise'in'
concentration."
• Preferably'most'proteins'should'be'supplied'from'animal'sources'
such'as'meat,'milk,'eggs,'cheese,'poultry'and'fish'because'they'
furnish'amino'acids'in'optimal'combinations."
• Philippine'Standard'[RENI,'FNRI\DOST]'on'additional'protein'in'
grams'per'day:"
o 1st"trimester:"1.6"
o 2nd"trimester:"7.8"
" o 3rd"trimester:"13.8"
" o Average"of"6g/day"for"the"whole"duration"of"pregnancy"
! "
! Carbohydrates"
! • Daily"intake"of"150!g!in"the"1st"trimester;"increased"thereafter"to"
! 225!g!at"the"end"of"pregnancy""

8"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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! !
!
• 507100!g/day!is"sufficient"to"prevent"ketosis"" o represents"2.5%"of"total"maternal"calcium"which"can"readily"
• Ample"amount"to"lessen"nausea"and"vomiting"" be"mobilized"for"fetal"growth""
" • Increased"calcium"absorption"by"the"intestine"and"progressive"
Fats! retention"throughout"pregnancy""
• Minimum"daily"intake"of"15725!g!! • Calcium"supplements"are"given"to"prevent"muscle"cramps"due"to"
" depletion"of"calcium"stores""
Dietary!Fiber! !
• Promotes!normal!bowel!movements!&"provides"bulk"or"satiety" 3.!Phosphorus!!
value"to"meals" • Same"as"in"nongpregnant"women""
!
Minerals! 4.!Zinc!!
1.!Iron! • Helps"in"wound"healing""
• Total"zinc"plasma"pool"is"increased"due"to"large"increase"in"
pregnancyginduced"plasma"volume""
• Incorporated'in'multivitamins'
• Recommended'intake'during'pregnancy'is'approximately'12mg'
• Deficiency!leads"to:""
o poor"appetite""
o subgoptimal"growth""
o impaired"wound"healing""
o dwarfism""
o hypogonadism""
o acrodermatitis!enteropathica:"specific"skin"disorder"as"a"
result"of"rare,"severe"congenital"zinc"deficiency""
"
5.!Iodine!"
• To"offset"the"increased"fetal"requirements"and"maternal"losses""
• Deficiency"leads"to"endemic"cretinism"characterized"by"multiple,"
severe"neurological"defects""
"
6.!Manganese,!Magnesium,!Chromium!and!Flouride"
!
• Important"for"brain"development"" • No"need"for"supplementation""
• Of'the'approximately'1,000'mg'of'iron'requirement'for'normal' "
pregnancy,'about'300'mg'are'actively'transferred'to'the'fetus'and' 7.!Copper!!
placenta'and'another'200'mg'are'lost'through'various'normal' • Cytochrome!oxidase!7!!play"key"roles"in"many"oxidative"
routes'of'excretion,'primarily'GIT' processes"and"in"the"production"of"most"of"the"energy"required"
• Average"requirement"for"pregnant:""6!mg/day!+"1mg"to" for"metabolism"
compensate"for"maternal"execution"="7!mg/day!" • Marked"increases"in"serum"ceruloplasmin"and"plasma"copper"
• 30"mg"of"iron"supplied"in"the"form"of"a"simple"iron"salt"such"as" during"pregnancy"
ferrous"gluconate,"sulfate"or"fumarate"" • Several"prenatal"supplements"currently"marketed"provided"2"
• 60!mg!–!100!mg:""if"woman"is"large,"has"twin"fetuses,"↓" mg"of"copper"per"tablet""
hemoglobin"" "
• 200!mg:'overtly'anemic'patients' 8.!Potassium!"
• Iron"supplements"are"given"to"patient"with"very"low"hgb,"but"if" • May"give"banana"or"sports"drink""
normal"supplement"is"given"on"the"3rd"trimester"(after'the'4th' • Maternal"plasma"concentration"decrease!by!about!0.5!meq/l!
month'or'the'last'3'month'of'pregnancy);"otherwise,"it"can" by"midpregnancy""
stimulate"vomiting"" • Indicated'for'patients'with'prolonged'nausea'and'vomiting'that'
• “As'little'as'30'mg'of'elemental'iron,'supplies'as'ferrous'gluconate,' may'lead'to'hypokalemia'(hydrate'using'IV'fluids)'and'metabolic'
sulfate'or'fumarate'and'taken'daily'throughout'the'latter'half'of' alkalosis'
pregnancy,'provides'sufficient'iron'to'meet'requirements'of' '
pregnancy'and'protect'preexisting'iron'stores.”" 9.!Sodium!!
• The'pregnant'may'benefit'from'60'to'100'mg'of'iron'per'day'if'she' • Deficiency"is"unlikely"unless"diuretics"are"prescribe"or"dietary"
is'large,'has'twin'fetuses,'begins'supplementatio'late'in'pregnancy,' sodium"is"reduced"drastically""
takes'iron'irregularly,'or'has'depressed'hemoglobin'level." • Sodium"excretion"remains"unchanged,"and"averages"1007110!
• Generally,'iron'requirements'are'slight'during'the'first'4'months'of' meq/l!!
pregnancy'thus'iti'is'not'necessary'to'provide'supplemental'iron' !
during'this'time." Vitamins!
• Hgb!must!be!>!13.3!" 1.!Folic!Acid!"
• Hgb">"13.2/dL"at"13g14"wks"had:"" • May"be"given"several"weeks"before"the"planned"pregnancy""
o Excessive"perinatal"mortality"" • Supplementation"before"conception"significantly"reduced"the"
o Low"birth"weight"" incidence"of"recurrent"neural!tube!defects!"
o Preterm"delivery"" • A'woman'with'prior'child'with'a'neural\tube'defect'can'reduce'the'
o Pregnancy"induced"hpn" 2'to'5'percent'recurrence'risk'by'more'than'70'percent'with'daily'
" 4mg'folic'acid'supplements'the'month'before'conception'and'
2.!Calcium!" during'the'first'trimester."
• Pregnant"woman"retains"about"30g!of"calcium,"most"of"which"is" "
deposited"in"the"fetus"late"in"pregnancy" 2.!Vitamin!A!

9"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
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!
• Vitamin'A'deficiency,'whether'overt'or'subclinical,'was'associated'
with'an'increased'risk'of'anemia'and'spontaneous'preterm'birth!
!
3.!Vitamin!B12!"
• Maternal"levels"decreases"due"to"reduction"in"plasma"
transcobalamins"[carrier"proteins]"
• Excessive"ingestion"of"vitamin"C"also"can"lead"to"a"functional"
deficiency"of"vitamin"B12""
• Strict"vegetarians"give"birth"to"infants"with"very"low"B12"levels""
"
4.!Vitamin!B6!"
• 2.5!mg/day!(2"mg!according"toWilliams)""
"
5.!Vitamin!C!"
• 70mg/day!+!10mg/day!"
• RDA"during"pregnancy"is"80785!mg/day!or"about"20%"more"
than"nongpregnant"women"(Williams)""
• Maternal"plasma"level"declines"during"pregnancy,"whereas"cord"
level"is"higher,"a"phenomenon"observed"with"most"watergsoluble"
vitamins."
"
6.!Vitamin!D!&!E!!
!
*Note:'Vitamin'intake'more'than'twice'the'RDA'should'be'avoided'
during'pregnancy'because'some'nutrients'like'Fe,'Zn,'Se,'Vit.'A,'B6,'
C'and'D,'can'potentially'exert'toxic'effects.'
'
GENERAL!HYGIENE:!Common!Concerns!
Exercise!
Exercise!is!contraindicated!in!the!following!conditions:!
!
• Heart"diseases"" "
• IUCR"" Employment!
• Severe"hypertensive"disease"and"Pregnancy"induced" • [Williams]"With'physically'demanding'work,'women'had'20\60'
hypertension"" percent'increase'in'rates'of'preterm'births,'fetal\growth'
• Ruptured"membranes"" restriction,'or'gestational'hypertension"
• Uterine"bleeding"" • [Higgins'and'associates,'2002]'Women'who'worked'had'a'fivefold'
• At"risk"for"premature"labor"" risk'of'preeclampsia"
• With"two"or"more"fetuses"" • Birth!weight!of!infant!whose"mother"worked"during"3rd"
• Susceptible"growth"retarded"fetus"" trimester"is"1507400!g!less"than"those"whose"mother"did"not"
• Anemia"" work""
• Thyroid"disease"" "
• Diabetes"" Travel"
• Breech"presentation"in"the"last"trimester"" • No"harmful"effect"on"pregnancy"
• Excessive"and"extreme"obesity"" • Women"can"safely"fly"up"to"36"weeks"
! • Women'should'wear'properly'positioned'three\point'restraints'
Women!who!benefit!from!a!very!sedentary!existence:!! throughout'the'pregnancy'while'riding'an'automobile"
• Women"with"pregnancy"induced"HPN"" • The'lapbelt'portion'of'the'restraining'belt'should'be'placed'under'
• With"two"or"more"fetuses"" the'abdomen'and'across'the'upper'thighs;'the'belt'should'be'
• Women"suspected"of"having"a"growth"retarded"fetus"" comfortably'snug"
• Severe"heart"disease"" • Shoulder'belt'should'be'snugly'positioned'between'the'breasts"
• Placenta"previa"" • For'air'travel,'pregnants'should'observe'same'precautions'for'air'
• Threatened"abortion"" travel'as'the'general'population,'including'periodic'movement'of'
• Premature"contractions" the'lower'extremities'ambulation'at'least'hourly'and'use'of'
" seatbelt'while'seated"
" "
" "
" "
" "
" "
" "
" "
" "
" "
" "
" "
" "

10"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
!
 History!Taking,!Diagnosis,!and!Prenatal!Care!
! !
!
• Tetanus"toxoid"is"safe"(6"wks"to"6"mos,"0.5"mL,"IM)""
"
Refer'to'POGS'guidelines'for'immunization'
IMMUNOLOGICAL!
INDICATIONS!DURING!PREGNANCY"
AGENT"
LIVE!ATTENUATED!VIRUS!VACCINES"
Measles!" Contraindicated""
Mumps!" Contraindicated""
Rubella!" Contraindicated""
Not"routinely"recommended"except"to"those"
Poliomyelitis!"
at"risk"of"exposure""
Contraindicated"except"if"exposure"is"
Yellow!Fever!"
unavoidable""
Varicella!" Contraindicated""
OTHERS"
All"women,"regardless"of"trimester,"who"will"
Influenza!"
be"pregnant"during"influenza"season""
Indication"for"prophylaxis"not"altered"by"
Rabies!" pregnancy"
each"case"considered"individually""
Pregexposure"and"postgexposure"for"women"
Hepa!B!"
at"risk"infection""
" Pregexposure"and"postgexposure"for"women"
" Hepa!A!"
at"risk"infection"(international"travel)""
!Bathing!
INACTIVATED!BACTERIAL!VACCINES"
• No"contraindications"during"pregnancy"or"the"puerperium"
Indications"not"altered"by"pregnancy"
"
recommended"for"women"with:"
Clothing!
asplenia"
• Comfortable"and"nongconstricting"clothes! Pneumococcus!"
metabolic,"renal,"cardiac,"pulmonary"diseases"
! smokers"
Bowel!Habits! immunosuppressed""
• Iron"can"cause"constipation"" Indications"not"altered"by"pregnancy"
Meningococcus!"
• Give"iron"with"laxatives"(but"laxatives"can"cause"spasm"that"may" vaccination"recommended"in"usual"outbreaks""
be"mistaken"as"contractions)"" Not"recommended"routinely"except"for"close,"
• Recommend"high"fiber"diet"" Typhoid!" continued,"exposure"or"travel"to"
" endemic"areas""
Coitus! Limited"to"individuals"who"are"occupationally"
• It"is"generally"accepted"that"in"healthy"pregnant"women,"secual" exposed"
intercourse"usually"is"not"harmful" Anthrax!" vaccines"contain"no"live"virus"&"thus"would"
• Whenever"abortion"or"preterm"labor"threatens,"coitus"should"be" not"be"expected"to"pose"significant"risk"
avoided" to"the"fetus""
• Possible"injurious"effects"from"intercourse"late"in"pregnancy:"" TOXOIDS"
o Transient"bradycardia"" Lack"of"primary"series,"or"no"booster"within"
Tetanus7diphtheria!"
o Increased"uterine"tension"during"maternal"orgasm"induced" past"10"years""
by"vulvar"and"vaginal"manipulation"" SPECIFIC!IMMUNE!GLOBULINS"
o #"amniotic"Fluid"Infection"And"Increase"Perinatal"Mortality" Hepatitis!B!" Postgexposure"prophylaxis""
" Rabies!" Postgexposure"prophylaxis""
Douches! Tetanus!" Postgexposure"prophylaxis""
• Rarely"indicated"or"totally"not"allowed"" Should"be"considered"for"exposed"preganant"
! Varicella!" women"to"protect"against"maternal,"not"
Care!of!Breast!and!Abdomen! congenital,"infection""
• The"extent"of"striation"is"proportional"to"the"size"of"the"uterus" STANDARD!IMMUNE!GLOBULINS"
and"maternal"weight"gain"" Hepatitis!A!"
• Avoid"scratching"the"striae,"apply"lotion"" Hepatitis"A"virus"
Postgexposure"prophylaxis""
" vaccine"should"be"used"
Care!of!Teeth/Dentition! with"Hepatiti"A""
• Mother"should"drink"more"milk"and"should"be"given"calcium" immune"globin"! "
supplementation! Measles!" Postgexposure"prophylaxis""
• Periodontal'disease'has'been'linked'to'preterm'labor! "
• Pregnancy'is'not'a'contraindication'to'dental'treatment'including' Transers’!Note:"POGS'Immunization'for'Filipino'women'2015'
dental'radiographs! • Tdap'–'1'dose'of'Tdap'during'pregnancy'after'20'wks'AOG'
! • Without'previous'tetanus'immunization/unknown'tetanus'
! immunization'Hx'#'3'doses'of'Td'vax.'to'be'given'1'month'during'2nd'
Immunizations! trimester'
• MMR,"varicellagzoster"are"contraindicated"" "
• Immunoglobulins"(for"chicken"pox)"is"safe"" "

11"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
!

! !
!
Smoking!
• Should"be"avoided"completely""
" •
• !Adverse!effects:!!
o CO"and"its"functional"inactivation"of"fetal"and"maternal"Hgb""
o vasoconstrictor"effect"of"nicotine:"inducing"placental"abruption"
="reduced"placental"perfusion""
o reduced"appetite"="reduced"caloric"intake""
o decreased"maternal"plasma"volume""
o unexplained"predisposition"in"certain"women"to"ill"effects"of"
nicotine"that"persists"even"after"quitting""
" o
!Alcohol!
• Contraindicated""
• Heavy"drinking"throughout"pregnancy"can"result"in"serious"
obstetrical"complications,"notably"Fetal!Alcohol!Syndrome!(FAS)!
which"is"associated"with"high"neonatal"mortality"rate""
" o
Caffeine!
• Generally"recognized"as"safe""
• No"association"between"caffeine"consumption"&"birth"defect"or"low"
birth""
• Intake"during"pregnancy"be"limited"to"less!than!300!mg!daily,"or"
about"three!5oz!cups!of"percolated"coffee"(Williams)""
• !Effects:!!
o has"effects"on"catecholamine"metabolism""
o has"diuretic"effect"and"draws"calcium"and"fluid"out"of"the"body""
o coffee"and"tea"taken"with"cream"and"sugar"may"spoil"appetite""
o can"cause"mood"swings"and"interfere"with"adequate"rest""
o may"interfere"with"adequate"absorption"of"iron""
o may"interfere"with"absorption"of"iron""
o because"it"crossed"placenta,"it"has"been"theorized"to"cause"dm"
of"babies"because"they"may"build"up"in"the"fetal"pancreas"and"
damage"the"cells"that"produce"insulin""
o can"cause"gastritis""
" C'
Illicit!Drugs!
• Intrauterine"distress,"low"birth"weight"&"serious"compromise"as"a"
consequence"of"drug"withdrawal"soon"after"birth"are"well"
documented""
" for"fetal"risk"or"lacking.""
Medications!
• Benefits"must"outweigh"the"risks""
• With"rare"exceptions,"any"drug"that"exerts"systemic"effect"to"the"
mother"will"cross"the"placenta"to"reach"the"fetus""
" Category!D!
OTHER!COMMON!CONCERNS!DURING!PREGNANCY!
• Nausea!and!vomiting!
o Give"ice"chips,"crackers,"candies,"vitamin"complex"
o Hydrate"the"patient"
o Admit"the"patient"if"she"is"underweight"
• Backache!
o Relieved"by"avoiding"highgheeled"shoes"and"supine"position"
o minimize"prolonged"standing"and"walking"
• Varicosities!
o Wear"supportive"stockings"
o Avoid"prolonged"standing"
• Hemorrhoids!
o Give"mild"laxative"and"high"fiber"diet"
o Advise"sitz"bath,"fruit"juices"
• Heartburn!
o Avoid"acidic,"sour"foods,"fruit"juice"
o Avoid"spicy"food,"caffeine,"soft"drinks"
• Pica!
o Bizarre"craving"for"strange"foods"and"materials"that"are"hardly"
considered"edible"
12"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
!
History!Taking,!Diagnosis,!and!Prenatal!Care!
o Amylophagia:"ingestion"of"starch"
o Geophagia:"ingestion"of"clay"
Ptyalism!
o Profuse"salivation"
o Eat"chips,"candy,"crackers"
• Fatigue!
o Desire"for"excessive"periods"of"sleep"
o Have'to'rule'out'cardiac'or'respiratory'problem'
'
• Headache!
o Correct"error"of"refraction"
If"severe,"give"paracetamol"(though"sleep"is"the"best"remedy)"
o Rule"out"HPN"
• Leukorrhea!
o Profuse"vaginal"discharge"
o Normal:"white,"not"foulgsmelling,"no"itchiness"during"
pregnancy,"not"watery"""no"amniotic"fluid"
Abnormal:"foul"smelling,"green"or"yellow"in"color"
o Treatment:"vagina"suppository"(canesten)"
"
DRUGS!DURING!PREGNANCY!
Category!A!
• Controlled!studies!show!no!risk!
• Adequate,"wellgcontrolled"studies"in"pregnant"women"have"failed"to"
demonstrate"a"risk"to"the"fetus"in"any"trimester"of"pregnancy"
• Vitamins"(except"vit."A)"and"iron"
"
Category!B!
• No!evidence!of!risk!in!humans!
• Either"(1)"animal"findings"show"risk"but"not"in"humans,"or"(2)"if"no"
adequate"human"studies"have"been"done,"animal"findings"are"
negative"
o Antibiotics"(ampicillin,"cephalosporin)"
o Paracetamol!
o Metronidazole!–'some'consider'it'Category'B'other'as'Category'
"
Category!C!
• Risk!cannot!be!ruled!out!
• Human"studies"are""lacking,"and"animal"studies"are"either"positive"
• Potential"benefits"may"justify"the"potential""
o Cephalosporins!
o Metronidazole!
"
• Positive!evidence!of!risk!
• Investigational"or"postgmarketing"data"show"risk"to"the"fetus"
• Potential"benefits"may"justify"the"potential"risks"
• If"needed"in"a"lifegthreatening"situations"or"serious"disease,"the"drug"
may"be"acceptable"if"safer"drugs"cannot"be"used"or"are"ineffective""
"
Category!X!
• Contraindicated!in!pregnancy!
• Studies"in"animals"or"humans,"investigations"or"post"marketing"
reports"have"demonstrated"positive"evidence"of"fetal"abnormalities"
or"risk"which"clearly"outweigh"any"possible"benefit"to"the"patient"
o Teratogens"(chemo"drugs)"
o Sedatives"(thalidomide"causes"phocomalia)"
o Smoking!
o Hormones"(contraceptives,"vita"derivatives)"–"Clomiphen,"Oral"
contraceptives,"Diethylstilbestrol,"Estradiol,"ethinyl"estradiol,"
Conjugated"estrogen,"Mestranol,"Anazol"
o Antineoplastic!agents/!anti7metabolites!–"Aminopterin,"
Methotrexate,"Cyclophosphamide"
 History!Taking,!Diagnosis,!and!Prenatal!Care!
! !
!
o Anti7microbials"g""Tetrayclines,"Aminoglycosides,"
Sulfonamides"
o Anti7fungals"–"Griseofulvin,"Fluconazole,"itraconazole"
o Vitamin!a!derivatives"–"Etretinate,"Isotretinoin,"Acitretin"
o Anti7malarials"–"Quinine"
o Vaccines!–"MMR,"HPV"
o Others"–"Disulfiram,"Lsd,"Marijuana"
"
"
"

13"of"13! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
!
! 1.06!
August!22,!2016!
IMMUNIZATIONS!
Dr.!Alicia!D.!Bautista!
Department"of"Obstetrics"and"Gynecology"

RECOMMENDED! AVAILABLE!
VACCINES!
TARGET!POPULATION! DOSE!REGIMEN! CONTRAINDICATIONS! PRECAUTIONS! ADVERSE!EFFECTS!
PREPARATIONS!
!

Gen!Adults:!!
a) "person" with" 0," inc," or"
unknown" primary"
series" of" tetanus"
immunization"
!primary" series"
TetanusFDiptheria""
b) Persons" who" have"
Mild:"
completed" primary"
• pain"(8"in10)"
series" !" booster" Td"
• redness/" swelling"
every"10"years""
(1"in"3)"
Preferences:!!
• mild" fever" (1"
• Td" over" TT" d/t"
in15)"
additional" protection" Primary!series!:!!
• headaches" or"
against"diphtheria" • 3" Td" IM"
tiredness"
• TT" –" only" for" booster," injections""
If"with"history"of" (uncommon)"
only" preferred" if" there" • 1st" 2" dosesF" 1"
arthusFtype" ""
TetanusFDiphteria! is"a"contraindication"to" mo"apart"" TT"–"0.5"ml/"ampule""
Severe"allergic"reaction"after" hypersensitivity" Moderate:!!
and!TetanusF diphtheria"component!" • 3rd" dose" –" 6F" 12" Tdap" absorbed" –" 0.5"
previous"dose"or"to"vaccine" reaction"ff"a"previous" • fever" >102°F"
DiphtheriaF Pregnant:! mo" after;" may" ml/syringe""
component"" TT"dose"!"defer"for"at" (rare)"
Pertussis! a) No" previous" tetanus" be" given" as" Td"–"0.5"ml/syringe"
least"10"years"from"TT" • extensive"
immunization" or" Tdap""
dose"" swelling" of" arm"
unknown" Tdap!dose:!!
where" shot" was"
immunization" history" • 0.5"ml,"IM"at"
given"(3"in100)""
!" 3" doses" of" Td" deltoid"
"
vaccine,"1"month"apart"
Severe!(rare):!!
starting" at" 2nd"
• swelling"
trimester"(3rd"dose"can"
• severe"pain""
be" given" postpartum"
redness"in"arm"
(Tdap))"
where"shot"was"given"
b) Last" Td/Tdap" >" 10"
years"!"Td"booster"in"
2nd"and"3rd"trimester"
"
For! persons! >! 65! years!
old! ! (w/! or! w/o! close!
contact! w/! infant! <12!
mo):!Tdap!!

1"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
 Immunizations!
! !
Bivalent!HPV:!!
a) can" be" given" to" those"
aged"10"–"14"years"and"
26"–"55"years""
b) protects" 15" to" 25Fyear"
olds"from:""
i. persistent" HPV"
infection""
ii. ≥cervical"
intraepithelial"
neoplasia" (CIN" 2+)"
and" CIN" 2+"
Bivalent!HPV:!!
associated" to"
• IM" injection" –" 0," 1" and"
combined"
6"months""
nonvaccine"
• Can" be" given"
oncogenic" HPV"
concomitantly" with"
types"[HPV"33,"45])"
dTpa,"IPV,"HepA,"HepB"
Quadrivalent!HPV:!!
"
a) Can"be"given"to"those"
Quadrivalent!HPV:!!
aged"9F45"years""
• IM" injection" –" 0," 2" and"
b) Protects"9"to"45Fyear" • Pregnant"" Observe"for" Bivalent"HPV"–"0.5"ml/"
6"months""
Human!Papilloma! olds:"" • With"acute"illness"" syncope"within"15" syringe""
• Can" be" given" "
Virus!(HPV)! i. Persistent" HPV" History"of"adverse"reactions" min"after" Quadrivalent"–"0.5"
concomitantly" with"
infection" to"any"vaccine"components"" administration" ml/syringe"
diphtheria," tetanus,"
ii. ≥" cervical"
pertussis," poliomyelitis"
intraepithelial"
vaccine" in" healthy"
neoplasia"(CIN"2+)""
adolescents" (11F17"
iii. Anogenital"warts""
years)"
"
"
Other:!!
Note:"These"two"are"not"
• Pap" smear" and" HPV"
interchangeable.""
infection" not" prereq" for"
"
HPV"vaccination"(GPP)"
• HPV" can" be" given" in"
women" with" special"
situations"(GPP):""
a) "Abnormal" Pap"
smear""
b) History"of"genital"
warts""
c) Breastfeeding""
d) Immunocompro
mised"
"
Routine:!! • Two" 0.5" ml" doses" of" • History" of" anaphylactic" • Postponement" of" • Varicella"Virus"
For! groups! with! no! singleFantigen" varicella" reaction"to"any"component" vaccination" until" Vaccine:"Live—"
evidence!of!immunity!of! vaccine," SQ," 4F8" weeks" of"vaccine"or"to"neomycin" recovery"from:"" attenuated,"freeze—
Varicella!Zoster! varicella!! apart" • With"malignant"conditions:"" o Untreated," active" dried"with"separate"
"
Virus! a)" ">"13"years"old"" • If">"8"weeks"elapsed" i. Blood"dyscrasias"" TB"" diluent,"to"be"
b)" "SchoolFaged" after"1st"dose,"2nd"dose" ii." Leukemia"" o Acute," severe" reconstituted"right"
children," college" may"be"administered" iii."Lymphoma"of"any"type"" illness" before"
students" and" without"restarting"the" iv."Other" malignant" • D/t" possible" administration""!"

2"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
 Immunizations!
! !
students" in" other" schedule." neoplasms" involving" inhibition" of" 0.5"ml"
postFsecondary" bone" marrow" or" response"to"vaccine," !
educational" lymphatics" do" not" administer"
institutions"" • Family" history" of" at" same" intervals"
!
c)" Other" healthy" congenital" or" hereditary" as:"" !
adults:"" immunodeficiency" in" 1st" i." Measles" (3F11" !
i." Health" care" degree" relatives" unless" mo," depending"
professionals"" proven" to" be" immune" on"dosage)"" !
ii." Household" competent"by"a"lab" ii." Administration" !
contacts" with" • Those" receiving" highFdose" of" blood" (except"
immunocompromi systemic" washed" RBCs)," !
sed"persons"" immunosuppressive" plasma," or" !
iii."Persons" who" live" therapy:"" immunoglobulin"
or" work" in" which" i." Oral" steroids" >" 2" mg/kg" • No" administration"
!
transmission" is" BW" of" antibodyF !
likely" (e.g." ii." Total" of" >" 20" mg/day" of" containing" product" !
residents" and" staff" prednisone" or" for" 2" wks" to" those"
in" institutional" equivalent" for" persons" who" have" just" !
setting" [teachers," who" weigh" <" 10" kg," received" !
etc.])" or" has" been" when" administered" for" vaccination" unless"
"
reported" >20"wks" benefits" exceeds"
iv."NonFpregnant" • Pregnant" those"of"vaccination"" "
women" of" • Recipient" should" be" "
childbearing"age"" revaccinated" or" "
v." Adolescents" and" tested"for"immunity" "
adults" living" in" at" appropriate" "
households" with" levels," depending" "
children"" on" the" dose" "
vi."International" received" and" then"
"
travelers"" revaccinated" if"
" seronegative" "
Postpartum:!" " "
• Prenatal" assessment" "
for" evidence" of" "
varicella" immunity" is" "
recommended" "
• Upon" completion" or" "
termination" of"
"
pregnancy," women"
without" varicella" "
immunity" should" "
receive"1st"dose"before" "
discharge" from" healthF "
care"facility"" "
• 2nd" dose:" 4F8" weeks" "
after"1st"dose"" "
• Avoid" conception" for" 1"
"
mo"after"each"dose!
" "
" "
" "
" "

3"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!

! !
• 0.5"mL,"SQ"(1F2"doses)"
• 2nd"dose:"4"weeks"after"
• All"nonFpregnant"
women"of"childbearing" • Indicated"for:"
age"
• Women"who"upon"
completion"or"
termination"of"
pregnancy"have"no"
Measles,!Mumps! serologic"evidence"of"
and!Rubella! immunity"or"
Viruses!(MMR)! documentation"MMR"
vaccination"
For"all"pregnant"women"
who"lack"acceptable"
evidence"of"rubella"
immunity"→"routine"
prenatal"serologic"testing"
of"MMR!
• Pregnant"and"
breastfeeding"women"
→"inactivated"flu"
vaccine""
• Individuals"belonging"
to"high"risk"groups" • Pediatric"(aged"6"moF8"
a) Children:"6"mo–18"
yrs"
b) Adults"≥"50"years" • Women"≥"19"years"old"à"
Influenza!Virus!
old""
c) Persons"at"risk"for"
medical"
complications"from"
influenza,"their"
household"and"
close"contacts""
• All"health"care"
professionals"
4"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
Immunizations!
• MMR,"live" "
attenuated"–"0.5"mL"
• Women" • Storage"
administered"MMR" requirements:"
1st"dose"(recommended"
→"don’t"get" o Vaccine:"ref"(2⁰"
for"adult)"
• Severe"allergic"reaction" pregnant"4"weeks" to"8⁰C)"
after"previous"dose" after"vaccination" immediately"
o Recently"exposed"to"
• Pregnancy" • Receipt"(≤11"mo)" upon"arrival."
measles/mumps"or"
• Severely" of"AbFcontaining" Protect"from"
are"in"outbreak"
immunocompromised"px" blood"product" light"at"all"times"
setting"
i. Hematologic"&"solid" (specific"interval" (exposure"may"
o Vaccinated"
tumors" depends"on" deactivate"
previously"with"killed"
ii. Receipt"of" product)" viruses)"
measles"vaccine" !
chemotherapy" • Hx"of" o Diluent:"may"be"
o Vaccinated"with"
iii. Congenital" thrombocytopenia" reffed"or"stored"
unknown"type"during"
immunodeficiency" or" at"room"temp"
1963F1967"
iv. LongFterm" thrombocytopenic" (20⁰"to"25⁰C);"
o Students"of"
immunosuppressive" purpura" don’t"freeze"or"
postsecondary"
therapy" • Need"for"tuberculin" expose"to"
educational"
v. HIV"px" skin"testing" freezing"temp"
institution"
! • Moderate"or"severe" After"reconstitution,"
o Works"in"a"health"
acute"illness"w/"or" use"immediately"or"
care"facility"
w/o"fever" store"at"2F8⁰C"and"
Plans"to"travel"
! protect"from"light"
internationally!
(discard"if"not"used"
w/in"8"hrs)!
• Inactivated"splitF
• GuillanFBarre" influenza"virus"
yrs)""F"refer"to"PPS"
Severe"allergic"reactions" syndrome:"within"6" vaccine"–"0.5"ml"
guidelines)"
after"a"previous"dose"or"to"a" weeks"of"previous" prefilled"syringe"
vaccine"component," dose"of"flu"vaccine" " • Inactivated"
IM,"yearly"(as"soon"as"
including"egg"protei" " • Moderate"to"severe" Influenza"virus"
WHOFrecommended"
" acute"illness"w/"or" vaccine"–"0.25"ml"
vaccine"becomes"
w/o"fever" and"0.5"ml"prefilled"
available)"
syringe"
 Immunizations!
!
• High"risk"patients"who"
have"not"received"prior"
immunization"or"prior"
vaccination"status"is"
unknown:""
o ≥"50"years"old,"
particularly"those"
living"in"institutions""
o Persons"with"
underlying"chronic"
medical"conditions:"
Chronic"CV"disease;""
Chronic"pulmonary"
• PPSV"and"
disease;"SickleFcell"
pneumococcal"
disease;"DM;"
conjugate"vaccine"
Alcoholism";"Chronic"
(PCV)"→"relatively"
liver"disease;"CSF" • Hypersensitivity"to"any"
safe""
leaks"or"cochlear" component"of"the"vaccine"
o Mild"side"effect:"" • PPSV:"licensed"for"
implants;"Functional" (Epinephrine"[1:1000]"
in"30"F50%" persons"≥"2"years,"
anatomic"asplenia" must"be"available"in"case"
→local" and"recommended"
• Immunocompromised" of"anaphylaxis)""
erythema" for"persons"with"
persons"≥"2"yrs"of"age:" • Severely"compromised"CV"
Pneumococcal! o In"children,"10"–" certain"underlying"
HIV"or"AIDS,"Leukemia," 0.5"mL,"IM"or"SQ" and/or"pulmonary" "
Bacteria! 20%"present" medical"conditions"
Hodgkin’s"disease," infection"(since"systemic"
with"local" and"for"all"persons"
lymphoma,"multiple" reactions"incurs"
erythema," aged"≥"60years""
myeloma,"generalized" significant"risks)""
tenderness"or" • PPSVF23"–"0.5"ml"
malignancy,"chronic" • Contraindication"in"
swelling"and" prefilled"syringe"
renal"failure,"nephritic" children"<"2"years"is"not"
11%"had"lowF
syndrome," established."
grade"fever"""
immunosuppressive"
Serious(allergic(
chemotherapy,"
reaction(→((
radiation"therapy,"
uncommon(
functional"or"anatomic"
asplenis,"organ"or"bone"
marrow"transplant"
recipients"
• Smoker"(19F49"years"
old)"with"asthma"
• Revaccination"with"
PPSV"with"a"lapse"at"
least"5"years"after"1st"
dose"with"these"groups:""
o ≥"50"years"old""
o 2F49Fyear"old"with:"
damaged"spleen"or"

5"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
 Immunizations!
!
asplenia,"sickleFcell"
disease,"HIV"
infection"or"AIDS,"
generalized"
malignancy,"
leukemia,"lymphoma,"
multiple"myeloma,"
nephritic"syndrome,"
organ"or"boneF
marrow"transplant,"
longFterm"steroid"
therapy,"
chemotherapy"and"
radiation"therapy""
• Pregnant"and"
breastfeeding"women"
who"are"at"high"risk"for"
invasive"pneumococcal"
disease""
• Administer"during"the"
2nd"or"3rd"trimester"as"
a"safety"precaution."
HighFrisk"women"
should"be"vaccinated"
before"pregnancy.""
d) High"risk"women:"
See"those"listed"in"
first"2"bullets"(DM"
or"GDM"is"included"
as"well)"
Women:!!
• ≥"18"years"old"with"
close"contact"with" • Severe"or"lifeFthreatening"
persons"with"Hep"A" allergic"reaction"to"a"
• traveling"to"or"working" previous"dose""
• Inactivated"Hep"A"
in"countries"with"high" • Severe"of"allergic"reaction"
Vaccine"–"1"ml/vial""
or"intermediate" Hep"A":"IM,"2"doses"→"6F12" to"any"of"the"vaccine’s" Expected"local"
• Combined"
Hepatitis!A! prevalence"of"Hep"A"" mo"apart,"for"lasting" components"" " reaction"at"site"of"
inactivated"Hep"A"
• User"of"street"drugs" protection" • Moderate"or"severe"illness" injection"
and"B"Vaccine"–"1"ml"
• With"chronic"liver" at"time"of"vaccination""
prefilled"syringe"He"
disease"(including"Hep" • Contraindication"for"
B"and"C)"" pregnancy"is"not"
• Previously"treated"with" determined."
clotting"factor"
concentrates"

6"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
 Immunizations!
!
• With"occupational"risk"
including"lab"staff"
PostFexposure!
prophylaxis:!
• Susceptible"healthy"
women"up"to"40"years"
old"→"singleFantigen"
Hep"A"ASAP"after"
exposure""
• ≥"40"years"old"→"Ig"
preferred"but"vaccine"
can"be"used"if"Ig"not"
available"
Women!≥!18!yrs!old!
who!belong!to:!!
• Health"care"and"public"
safety"and"security"
workers"who"may"have"
exposure"to"blood"in"
workplace""
• Persons"in"training"for"
allied"health"
professionals""
• Hemodialysis"patients"
• Severe"allergic"reaction"to"
and"those"receiving"
vaccine"component"or"to"
blood"and"blood" • Hep"B:"IM.,"3"doses"(at"0,"
prior"dose""
products"including" 1,"6F12"mo)"
• Moderate"or"severe"acute"
transplant"candidates"" • Accelerated"sched:"4" Recombinant"Hep"B"
illness"→"delay"
Hepatitis!B! • Patients"in"early"course" doses"–"0,"1,2,"12"mo"" " " virus"vaccine"–"20"
administration"until"
of"chronic"liver"disease"" • Rapid"sched:"4"doses"–"0," mcg/ml,"5"ml"
condition"improves""
• STD"clinic"clients"" 7,"21"days"and"12"
• Minor"illnesses"(like"upper"
• Multiple"sexual" months"
respiratory"tract"
partners"or"prior"STD"
infection)"
• Inmates"in"correctional"
facility""
• Clients"and"staff"of"
institutions"for"
developmental"
disability""
• Travelers"to"high"
endemicity"areas""
• Overseas"foreign"
workers""
• Injection"drug"users""

7"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!
 Immunizations!
!
• Household"contacts"and" "
sexual"partners"of"hep"
B"virus"carriers""
Other:!!
• May"be"administered"to"
pregnant"women""
• All"HBsAgFnegative"
pregnant"women"
seeking"treatment"who"
have"not"been"
previously"vaccinated"
"
"

8"of"8! ["OB!Girls"!"Faye,"Gabby,"Jade,"Jelyn,"Vien"]""
!